Provider Demographics
NPI:1376674812
Name:TRIPP, VICKI (SLP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:TRIPP
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 PENNSYLVANIA ST NE
Mailing Address - Street 2:COMANCHE ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-2310
Mailing Address - Country:US
Mailing Address - Phone:505-884-5275
Mailing Address - Fax:
Practice Address - Street 1:3505 PENNSYLVANIA ST NE
Practice Address - Street 2:COMANCHE ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-2310
Practice Address - Country:US
Practice Address - Phone:505-884-5275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMK 6061Medicaid